Provider Demographics
NPI:1366004731
Name:SUMRALL DRUG STORE LLC
Entity Type:Organization
Organization Name:SUMRALL DRUG STORE LLC
Other - Org Name:SUMRALL DRUG STORE LONG TERM CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TASHA
Authorized Official - Middle Name:F
Authorized Official - Last Name:HADEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-758-4243
Mailing Address - Street 1:PO BOX 120
Mailing Address - Street 2:
Mailing Address - City:SUMRALL
Mailing Address - State:MS
Mailing Address - Zip Code:39482-0120
Mailing Address - Country:US
Mailing Address - Phone:601-758-4243
Mailing Address - Fax:601-758-4999
Practice Address - Street 1:1109 HWY 42
Practice Address - Street 2:
Practice Address - City:SUMRALL
Practice Address - State:MS
Practice Address - Zip Code:39482
Practice Address - Country:US
Practice Address - Phone:601-758-4243
Practice Address - Fax:601-758-4999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-05
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy